GW1-2022-08413_Well Construction - GW1_20220527

WELL CONSTRUCTION RECORD(GW-1,) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL ,-M WATE13"ZONES<,
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4459 ft. ft.
NC Well Contractor Certification Number OUTER CASING"formulti-cased wells OR LWER if a `licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. fr. is
Company Name
16 INNER CASING ORTUBING16-6th6rrnal"closed-loo
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance.etc.) 0,0 fr. 15.0 ft 2.0 1° SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.,SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15.0"' 30.0 ft. 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑hldustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT , ,n
❑lrrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 10.0 ft' PORTLAND BENTOWE SLURRY
MMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge El Groundwater Remediation
19.SAND/GRAVEL"PACK ifa lic'able.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StonnwaterDrainage 13.0 fr' 30.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer .'20 DRILLING LOG`attach additionat`sheets if necissa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0.0 ft- 5.0 ft- FILL
4.Date Well(s)Completed: 05/18/22 Well ID# MW-6 5.0 ft- 30.0 ft SILTY SANDY CLAY
5a.Well Location: ft. ft.
A CLEANER WORLD - 150 ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
3735 PETERS CREEK PARKWAY WINSTON SALEM 27127 ft. fr.
Physical Address,City,and Zip
ft. ft.
FORSYTH zl"REMARKS'
County Parcel Identification No.(PIN) BENTONIfE SEAL- 10.0-13.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
360 01' 10.68" N 800 15' 36.90" W � � ,� �
05/26/22
6.Is(are)the well(s): TlPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or INNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additio II construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS V1A,9 2 7 2. ?2
9.Total well depth below land surface: 30.0 (ft.)
For multiple wells list all depths ifdifferem(example-3@200'and 2@I00) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 20.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+„
11.Borehole diameter: 8.0 (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018